For citation purposes: Erick P, Smith D. Musculoskeletal disorder risk factors in the teaching profession: a critical review. OA Musculoskeletal Medicine 2013 Dec 01;1(3):29.

Critical review

 
Prevention

Musculoskeletal disorder risk factors in the teaching profession: a critical review

P Erick*, D Smith
 

Authors affiliations

School of Health Sciences, University of Newcastle, Ourimbah, Australia

* Corresponding author E-mail: patience.erick@uon.edu.au

Abstract

Introduction

Musculoskeletal disorders (MSD) have been recognized as a considerable problem in the teaching profession and various risk factors have also been documented. The aim of this review was to review and discuss MSD risk factors among teachers.

Discussion

Individual factors such as female gender, age and teaching experience have been positively correlated with MSD in a number of studies. Poor posture, inappropriate furniture, lifting and carrying have also been associated with a high prevalence of MSD. Psychosocial factors such as poor colleagues and supervisor support, low job satisfaction and high job stress are known to be associated with MSD. On the other hand, regular physical exercise has been shown to be a protective factor in some studies.

Conclusion

Given the high burden of MSD documented in the teaching profession, further studies are now required to develop and implement effective intervention strategies to help reduce, and ultimately prevent, these conditions.

Introduction

Musculoskeletal disorders (MSD) represent a common occupational problem in the teaching profession and teachers represent an occupational group among which there appears to be a high prevalence of MSD. It has been suggested that the prevalence of self-reported MSD among teachers ranges between 39% and 95%[1]. The work of a teacher does not only involve teaching students but also preparing lessons, assessing students’ work and also being involved in extracurricular activities such as sports. Teachers also participate in different school committees. Teachers are essential for the effective functioning of the education system and for improving the quality of learning processes[1,2]. In some areas, teaching is done under unfavourable circumstances, in which teachers must mobilize their physical, cognitive and affective capability to reach a teaching production objective, overdemanding or generating effort to their psycho-physiology functions. If there is insufficient time for recovery, pain symptoms may be triggered or prompted. As a result, this may lead to stress, with consequences to physical and mental health and impact on professional performance[3].

Several work-related factors have been correlated with to the development of MSD in the teaching profession. These factors include high workload, for example, excessive paperwork, class preparation and students’ evaluation, lack of communication in the workplace, excessive demands from colleagues and supervisors. Work postures have also been related to MSD in the teaching profession[4]. In recent times, psychosocial factors have also emerged as potential risk factors for MSD. Despite their large demographic and the associated potential for occupational health problems, few studies have investigated MSD risk factors among teachers. An investigation of risk factors of MSD in the teaching profession is important for appropriate preventative and management strategies to be put in place.

The aim of this review was to critically analyse the literature and report on the possible associated risk and protective factors among teachers. The review focused on primary and secondary teachers including music and physical education teachers; and aimed to identify all articles that reported MSD risk factors among teachers. Nursery schools and tertiary institutions were excluded from the review. Empirical research in peer-reviewed English journals was included in the review, whereas letters to the Editor, conference proceedings and literature reviews were excluded.

Discussion

The authors have referenced some of their own studies in this review. These studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in referenced studies, gave informed consent to participate in these studies.

MSD is the result of the interaction between an affected person and a host of risk factors including those that are personal, physical and psychosocial in nature. The most notable risk factors among teachers include gender, age, smoking, weekly working hours, length of employment and awkward posture. Table 1 shows the risk factors that have been identified in this review.

Individual factors

Various studies suggest that the prevalence of MSD is often positively associated with the female gender. Females, representing a higher proportion of teachers often have a higher prevalence of MSD. This has been supported by findings from a number of studies where female teachers reported neck pain[2,5,6,7,8,9,10,11], shoulder pain[2,5,10,11], upper limb pain[2,3,8,12], back pain[2,3,5,7,10,11,13], and lower limb pain[2,3,7,14] more often than their male counterparts. In one study from Ethiopia, for example, this difference has been attributed to the nutritional status of females as they were seen to have been obese than males[13]. Another possible reason was that males were found to be involved in regular physical exercise more often than females[5,13]. However, in a study involving Chinese teachers, females might be suffering more emotional exhaustion compared with men because male teachers had a higher body mass index, longer employment than females, a significant higher proportion of smokers and often worked for more than 40 hours a week. This study also found that women bore more heavy housework responsibilities than men in daily life. Differences in household task participation may also explain musculoskeletal differences between men and women[6].

Table 1

Risk factors associated with musculoskeletal disorders by body site

In a study from Brazil, female school teachers were reported to have a higher MSD prevalence rate due to their working conditions. It was reported that although the majority of teachers are females, they are less qualified with low salaries, high work demands and have less control over their work than their male counterparts[3]. Among female music teachers, it is suggested that they suffer from MSD more often than their male colleagues because they are of a slighter build with less muscle power and thus need greater effort when playing. There are, however, other factors that should also be taken into consideration such as individual differences, anatomic variations, size, flexibility, and relationship to the instrument[15]. In addition, women may be more likely to report any pain problem than men as women tended to have a lower pain threshold than men. It has also been suggested that women are more likely to report pain than men because of pressure from family and career endeavours or simply because men and women have different traditions and thresholds for when and how to report pain[2]. It is concerning that results which show that female teachers are at an increased risk of MSD as the teaching profession is predominately female.

While MSD has been positively associated with age, research findings are somewhat inconsistent with some studies reporting increasing age as being associated with MSD, whereas others have reported that younger teachers are more likely to report MSD. A number of studies have reported a positive association between increasing age and the development of MSD. These studies found that teachers aged 40 years or over were more likely to report MSD of different body sites[3,7,8,11,16]. However, some studies have found that younger teachers have also reported MSD. Supporting this are the results of some Chinese studies where teachers aged 30 to 39 years reported the highest lower back pain prevalence[17] and where teachers aged 31 to 35 years reported the highest neck pain prevalence[8].

It has been suggested that the likely reason for a higher prevalence of MSD among older teachers is that as people age, there is a gradual decline in muscle mass and they lose connective tissue elasticity and undergo a thinning of the cartilage between joints. However, tissue healing also declines with advancing age whilst the body is simultaneously dealing with a lifetime of accumulated soft tissue damage[3,11,18]. Apart from natural wear and tear on the body, MSD among older teachers may also be influenced by work environment and the organisation of work[3]. It has been suggested that older teachers generally have reduced physical capabilities and slower physiological response when compared with their young colleagues[19]. In cases where younger teachers reported symptoms of MSD, it has been suggested that younger teachers face greater work demands thereby being exposed to more risk factors as they take more activities and tasks at the beginning of their careers[3].

Contradicting findings have been reported in the relationship between length of employment and the development of MSD. In some studies, longer length of employment has been associated with neck pain[7,8,9] and lower back[3,5,7]. However, conflicting findings were found in a Chinese study where the prevalence of shoulder pain was significantly higher for teachers with 1 to 15 years of teaching experience (p < 0.005) while those with 16 to 20 years teaching experience reported lower prevalence (p < 0.001)[2]. It has been suggested that the longer the exposure time to occupational risk factors, the higher the chance of getting job-related disorders[20]. This association may also be interpreted as an effect of aging or a cumulative effect of workloads on the musculoskeletal system of the workers[21]. Where teachers with lesser teaching experience have reported MSD, it has been suggested that may occur because new teachers may not be adapting well to the new working environment and physical and psychological stress might affect the wellbeing of their musculoskeletal conditions[8]. For new female teachers reporting MSD, it has been suggested that marriage and child care may be contributing factors[11]. Long working hours have also been positively associated with MSD in various studies[7,22,23]

Long weekly working hours expose teachers to factors such as prolonged standing, prolonged sitting or awkward posture all of which have been associated with back pain[22]. A number of other individual factors have also been correlated with MSD. In a Chinese study, for example, primary school teachers were more likely to experience neck pain (p < 0.01), shoulder pain (p < 0.001), leg pain during physical activity (p < 0.001) and arm pain (p < 0.001) than secondary school teachers[2]. Having more than 30 students in a class has been associated with upper limb pain (PR: 1.14, 95% CI: 1.02-1.28), while working at the same school for more than 5 years has been associated with lower limbs (PR: 1.12, 95% CI: 1.03-1.19), upper limbs (PR: 1.34, 95% CI: 1.19-1.50) and back pain (PR: 1.15, 95% CI: 1.07-1.24) among Brazilian school teachers[3]. In another Chinese study, taking no breaks during work (OR: 1.36, 95% CI: 1.02-1.82) and taking breaks after 3 or more hours of working (OR: 1.37, 95% CI: 1.07-1.75) were been associated with neck pain among school teachers[8]. Similarly, lack of exercise was significantly associated with MSD among school teachers in Turkey (p = 0.000)[11], whereas low physical activity in leisure time has been significantly correlated with neck pain among non-PE teachers in Estonia (p = 0.01)[24]. In addition, no personal training has been associated with increased risk for lower back pain among PE teachers (OR: 2.5, 95% CI: 1.2-5.3)[25].

Furthermore, perceiving one’s health worse than others (OR: 3.6, 95% CI: 1.10-13.6), physical exercise during leisure time (OR: 3.3, 95% CI: 1.10-9.60) and teaching at many schools more than 4 times per week (OR: 2.7, 95% CI: 1.10-6.8) have been significantly associated with neck/shoulder pain among female music teachers in Sweden[14]. Warm-up before practice has been associated with pain after playing piano (p < 0.01), while physical warm-up time spent has been associated with pain when playing (p < 0.05) and pain after playing (p < 0.01) among U.S. piano teachers[26]. In addition, other individual factors such as previous injury[13], smoking[7,13,19] body mass index[5], number of children[3,23] and teaching at high school compared with primary or secondary school[6] have also been positively associated with the development of MSD.

Physical factors

The known high prevalence of MSD among school teachers may be due to physical factors at work. This review has found that lifting heavy loads has been reported as a risk factor for shoulder, back and elbow pain among Turkish teachers[5]. In China, prolonged sitting and static posture and uncomfortable back support have been positively associated with neck/shoulder and lower back pain among teachers. Posture characterised by twisting has also been associated with development of lower back pain, whereas prolonged standing has been closely associated with neck/shoulder pain[6]. In another Chinese study, working with a ‘head down’ posture for more than 4 hours has been found to contribute to the development of neck pain among school teachers[8]. Among Swedish music teachers, lifting instruments and music equipment more than six times a day has been correlated with neck/shoulder pain[14]. In Brazil, intense physical activity and inappropriate furniture have been associated with back pain among teachers[3]. Helping students into flexing posture and lifting instruments among Greek school teachers has been shown to be highly correlated to lower back pain[25].

Psychosocial factors

There is increasing evidence for an association between psychosocial factors and MSD among teachers. Poor mental health status has been significantly associated with lower back pain among Malay primary school teachers (p < 0.001)[19], while stress significantly increased the risk of back pain among Filipino teachers by approximately four fold[22]. In a Chinese study of secondary school teachers, low colleague support, high anxiety, and high workload were significantly associated with neck pain. In the same study, high workload, very low colleague support and high anxiety were positively correlated with upper limb pain[8]. In addition, another study of Chinese secondary school teachers found a positive association between high workload, low colleague support, high job stress, low job satisfaction and neck pain[9]. Having stress among Ethiopian teachers was found to be a risk factor for lower back pain[13]. These associations may occur because teachers work in stressful conditions with large classes, lack of educational resources and limited reward for their work[3]. It has been reported that, the more psychological demands needed for a certain task, the greater the possibility to develop MSD regardless of the anatomical area[13].

Protective factors

Table 2 describes factors that have been negatively correlated with MSD, that is, protective factors. Physical exercise for 7 or more hours a week, for example, has been found to have a protective role against neck/shoulder pain in one study[6]. Regular physical exercise was also found to be a protective factor for lower back pain[13] neck and upper extremities[7]. It has been suggested that physical exercise may prevent lower back pain recurrences or chronicity. There is also strong evidence that endurance training including running, swimming, cycling or aerobic training might help prevent lower back pain. Interestingly, teachers aged 40 or above were found to be less likely to report neck and lower back pain in a study of Turkish teachers[7]. Another interesting finding was reported in a study of Turkish teachers, where body mass index was found to have a slight protective role for back pain. It has been suggested that this finding could be due to the tendency of people with higher body mass index to avoid prolonged standing and exertional activities. Medium job satisfaction were found to be protective factors against back pain among Chinese school teachers[17]. Having another paid activity acted as a protective factor against upper and lower limbs pain among Brazilian teachers[3]. Having own office and satisfaction with working environment and culture were negatively correlated to lower back pain among Ethiopian teachers[13].

Table 2

Protective factors for musculoskeletal disorders by body site.

Conclusion

An increasing body of evidence suggests a strong correlation between MSD and individual, physical and psychosocial factors in teaching. Individual factors such as gender, age, length of employment, working hours, smoking and body mass index are knonw to be associated with MSD. Among the physical factors, lifting heavy loads, prolonged sitting or standing, awkward postures and inappropriate furniture have been shown to be significant risk factors. Psychosocial risk factors have included poor mental health, low colleague support, high anxiety and low job satisfaction. Undertaking regular exercise, medium job satisfaction and satisfaction with working environment and culture have been found to contribute to reduction of MSD among teachers. This review has also identified some potential protective factors for MSD. As such, there is need to develop and implement effective intervention strategies that are aimed at curbing the development of MSD within the education profession. Appropriate intervention strategies may include ergonomically designed workplaces, proper equipment and training and reasonable job demands and workload, among others.

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Risk factors associated with musculoskeletal disorders by body site

Symptom Factor Participants OR* 95% Cl# p value Author
Neck pain Female gender School teachers 1.54 1.03-2.31 Baskurt et al.7
Primary, secondary and high school teachers 0 Korkmaz11
Primary and secondary school teachers 0.001 Chong and Chan2
Music teachers 0.02 Edling10
Secondary school teachers 2.39 1.97-2.91 0.001 Chiu and Lam8
Secondary school teachers 2.01 1.26-3.20 0.003 Chiu et al.9
Music teachers 0.02 Fjellman-Wiklund et al.14
Age (increasing) Secondary school teachers 3.01 2.08-4.37 0.0001 Chiu and Lam8
Teaching experience (increasing) Secondary school teachers 0.0001 Chiu and Lam8
Secondary school teachers 1.11 1.01-1.23 0.004 Chiu et al.9
School teachers 2.7 1.63-4.47 Baskurt et al.7
Teaching level (primary school) Primary and secondary school teachers 0.01 Chong and Chan2
Working in head down posture – average length of time > 4 hours Secondary school teachers 2.17 1.38-2.74 0.0001 Chiu and Lam8
Working in head down posture with maximal sustained time between 15 and 30 minutes Secondary school teachers 1.72 1.16-2.53 Chiu and Lam8
Working in head down posture with maximal sustained time between 1 and 2 hours Secondary school teachers 1.7 1.14-2.53 Chiu and Lam8
Taking no breaks during work Secondary school teachers 1.36 1.03-1.82 Chiu and Lam8
Taking breaks after 3 hours of working Secondary school teachers 1.37 1.07-1.44 Chiu and Lam8
Low physical activity in leisure time among non-PETs Non physical education teachers 0.01 Pihl et al.24
Intensive physical activity in leisure time among PETs Physical education teachers 0.05 Pihl et al.24
Maximal time of sustained computer work Secondary school teachers 1.69 1.33-2.16 <0.001 Chiu et al.9
Physical activity School teachers <0.05 Durmus and Ilhanli5
High workload Secondary school teachers 2.17 1.58-2.97 Chiu and Lam8
Secondary school teachers 1.72 1.12-2.65 0.013 Chiu et al.9
Very low colleague support Secondary school teachers 2 1.16-3.47 Chiu and Lam8
Secondary school teachers 1.73 1.36-2.20 <0.001 Chiu et al.9
High anxiety Secondary school teachers 1.49 1.07-2.07 Chiu and Lam8
High job stress Secondary school teachers 1.97 1.45-2.70 <0.001 Chiu et al.9
Low job satisfaction Secondary school teachers 1.3 1.04-1.63 0.02 Chiu et al.9
Shoulder pain Female gender Music teachers 0.025 Edling10
Primary, secondary and high school teachers 0.002 Korkmaz11
Music teachers 0.02 Fjellman-Wiklund et al.14
Primary and secondary school teachers 0.001 Chong and Chan2
Teaching experience (1-15) Primary and secondary school teachers 0.001 Chong and Chan2
Teaching level (primary school) Primary and secondary school teachers 0.001 Chong and Chan2
Neck/shoulder pain Female gender School teachers 1.84 1.25-2.71 Yue et al.6
Teaching at high school compared to primary and secondary schools School teachers 2.35 1.43-3.84 Yue et al.6
Prolonged standing School teachers 1.74 1.03-2.95 Yue et al.6
Prolonged sitting School teachers 1.76 1.23-2.52 Yue et al.6
Prolonged static posture School teachers 2.25 1.56-3.24 Yue et al.6
Uncomfortable back support School teachers 1.77 1.32-2.55 Yue et al.6
Perceived health (worse than others) – (female music teachers only) Music teachers 3.6 1.1-13.8 Fjellman-Wiklund et al.14
Physical exercise during leisure time – (female music teachers only) Music teachers 3.3 1.1-9.6 Fjellman-Wiklund et al.14
Teaching at many schools per week (more than 4 per week) – (female music teachers only) Music teachers 2.7 1.1-6.8 Fjellman-Wiklund et al.14
Lifting instruments and music equipment (>6 times per day) – Male music teachers only Music teachers 4.2 1.6-10.7 Fjellman-Wiklund et al.14
Playing guitar as a main instrument – Male music teachers only Music teachers 3.2 1.2-8.1 Fjellman-Wiklund et al.14
High psychological demands 9 female teachers only) Music teachers 6/0 1.1-32,4 Fjellman-Wiklund et al.14
Low social support (male teachers only) Music teachers 3.1 1.0-9.7 Fjellman-Wiklund et al.14
Upper extremities
Arm pain Female gender Primary and secondary school teachers 0.001 Chong and Chan2
Teaching level (primary school) Primary and secondary school teachers 0.001 Chong and Chan2
Elbow pain Female gender Physical education teachers 1.6 1.10-2.30 Sandmark12
Wrist pain Using computer per day School teachers <0.05 Durmus and Ilhanli5
Upper limbs pain Female gender Secondary school teachers 1.89 1.54-2.33 0.001 Chiu and Lam8
School teachers 1.74 1.18-2.56 Baskurt et al.7
Primary and secondary school teachers 1.59a 1.22-2.07 <0.001 Cardoso et al.3
Age (increasing) Secondary school teachers 3.8 2.33-6.21 0.0001 Chiu and Lam8
Primary and secondary school teachers 1.31a 1.10-1.56 0.01 Cardoso et al.3
Teaching experience (21-25 years) Secondary school teachers 0.0001 Chiu and Lam8
Teaching experience (increasing) Primary and secondary school teachers 1.39a 1.39-1.59 <0.001 Cardoso et al.3
Time working at school (> 5 years) Primary and secondary school teachers 1.34a 1.19-1.50 0.001 Cardoso et al.3
Number of students per class (>30 students) Primary and secondary school teachers 1.14a 1.02-1.28 0.05 Cardoso et al.3
Weekly schedule (40 hours) Primary and secondary school teachers 1.12a 1.01-1.26 0.05 Cardoso et al.3
Intense physical activity Primary and secondary school teachers 1.42a 1.27-1.59 0.001 Cardoso et al.3
Working in head down posture – average length of time > 2.5 – 5.5 hours Secondary school teachers 1.91 1.20-3.04 0.0001 Chiu and Lam8
Working in head down posture – average length of time > 4 hours Secondary school teachers 2.17 1.38-2.74 0.0001 Chiu and Lam8
Working in head down posture with maximal sustained time between 1 and 2 hours Secondary school teachers 1.72 1.07-2.75 Chiu and Lam8
High workload Secondary school teachers 2.07 1.41-3.04 Chiu and Lam8
Very low colleague support Secondary school teachers 2.15 1.32-3.50 Chiu and Lam8
High anxiety Secondary school teachers 1.75 1.28-2.39 Chiu and Lam8
Smoking School teachers 1.49 1.01-2.63 Baskurt et al.7
Back pain Female gender Music teachers 0.02 Fjellman-Wiklund et al.14
Primary and secondary school teachers 1.58a 1.31-1.90 <0.001 Cardoso et al.3
Age (30-39 years) School teachers 1.3 1.00-1.70 Jin17
Age (increasing) Primary and secondary school teachers 1.20a 1.07-1.35 <0.01 Cardoso et al.3
Teaching experience (increasing) Primary and secondary school teachers 1.2 1.09-1.59 <0.001 Cardoso et al.3
School teachers 1.8 1.3-2.4 Jin17
Teaching at high school compared to primary and secondary schools School teachers 2.01 1.24-3.27 Yue et al.6
Prolonged sitting School teachers 1.42 1.01-2.02 Yue et al.6
Prolonged static posture School teachers 1.6 1.11-2.31 Yue et al.6
Posture characterised by twisting School teachers 1.93 1.30-2.87 Yue et al.6
Uncomfortable back support School teachers 1.62 1.13-2.32 Yue et al.6
Time working at school (>5 years) Primary and secondary school teachers 1.15a 1.07-1.24 <0.001 Cardoso et al.3
Physical activity School teachers 1.71 1.09-2.68 <0.05 Durmus and Ilhanli5
Intense physical activity Primary and secondary school teachers 1.29a 1.20-1.38 <0.001 Cardoso et al.3
Inappropriate furniture Primary and secondary school teachers 1.11a 1.03-1.19 <0.001 Cardoso et al.3
Upper back pain Female gender ****Primary, secondary and high school teachers 0.004 Korkmaz11
Primary and secondary school teachers 0.001 Chong &Chan2
Music teachers 0.01 Edling10
Music teachers 0 Fjellman-Wiklund et al.14
Age (31-50) Primary and secondary school teachers 0.05 Chong &Chan2
Low back pain Female gender Primary and secondary school teachers 0.01 Chong &Chan2
School teachers 2.5 1.67-3.72 Baskurt et al.7
School teachers 3.23 2.10-5.26 0.001 Beyen et al.13
Age (years) School teachers <0.0001 Durmus and Ilhanli5
School teachers 2,34 1.34-4.07 0.008 Beyen et al.13
Working hours per day (5-6 hours/day) Secondary school teachers 1.88 Atlas et al.22
Working hours per day (7-8 hours/day) Secondary school teachers 2.5 Atlas et al.22
Teaching experience ≥10 years School teachers 2.78 1.71-4.56 Baskurt et al.7
Previous injury School teachers 1.96 1.04-3.69 0.037 Beyen et al.13
Working time >35 hours/week Physical education teachers <0.05 Stergioulas25
Poor mental health status Primary school teachers 1.11 1.06-1.15 0.001 Samad et al.19
Stress Secondary school teachers 4.15 Atlas et al.22
School teachers 2.18 1.36-3.50 Beyen et al.13
Helping students into flexing posture Physical education teachers 3 1.1 – 7.2 <0.05 Stergioulas25
Lifting gym instruments Physical education teachers 2.6 1.2 – 5.8 <0.05 Stergioulas25
No personal training Physical education teachers 2.5 1.2 – 5.3 <0.05 Stergioulas25
Smoking School teachers 2.65 1.11-6.32 0.028 Beyen et al.13
Lower limb pain
Leg pain Female gender Primary and secondary school teachers 0.001 Chong &Chan2
Teaching level (primary school) Primary and secondary school teachers 0.001 Chong &Chan2
Lower limb pain Female gender Primary and secondary school teachers 1.98a 1.57-2.38 <0.001 Cardoso et al.3
Primary and secondary school teachers 1.28a 1.01-1.38 <0.001 Cardoso et al.3
Age (≥40 years) School teachers 2.75 1.70-4.44 Baskurt et al.7
Teaching experience (increasing) Primary and secondary school teachers 1.14a 1.04-1.24 <0.01 Cardoso et al.3
Time working at school (>5 years) Primary and secondary school teachers 1.12a 1.03-1.19 <0.01 Cardoso et al.3
Weekly schedule (40 hours) Primary and secondary school teachers 1.09a 1.01-1.18 <0.05 Cardoso et al.3
Weekly working hours ≥25 hours School teachers 2.06 1.43-3.17 Baskurt et al.7
Intense physical activity Primary and secondary school teachers 1.42a 1.32-1.52 <0.001 Cardoso et al.3
Smoking School teachers 1.71 1.12-2.63 Baskurt et al.7
Feet Female gender Music teachers 0.01 Fjellman-Wiklund et al.14
Knee pain Body mass index School teachers 1.09 1.02-1.16 <0.01 Durmus and Ilhanli5
Intensive physical activity in leisure time Physical education teachers <0.01 Pihl et al.24
Any Female gender Primary and secondary school teachers 0.001 Chong and Chan2
Music teachers <0.05 Allsop and Ackland16
Age Female secondary school teachers 0.002 Darwish et al.23
Teaching level (primary school) Primary and secondary school teachers 0.001 Chong and Chan2
Teaching experience (1-15) 23 Primary and secondary school teachers 0.005 Chong and Chan2
Teaching experience Female secondary school teachers 0.003 Darwish et al.23
Not doing exercise regularly Primary, secondary and high school teachers 0 Korkmaz11
Warm-up before practice Music teachers <0.05 Yoshimura et al.26
Physical warm-up time spent Music teachers <0.01 Yoshimura et al.26
Years of playing (increasing) Music teachers <0.05 Allsop and Ackland16
Practice hours (increasing) Music teachers <0.05 Allsop and Ackland16
Age (increasing) Music teachers <0.01 Allsop and Ackland16
Using elevated shoulder posture when playing Music teachers <0.05 Allsop and Ackland16
Using neutral wrist posture Music teachers <0.01 Allsop and Ackland16
Taking 2 or more breaks during practice session Music teachers <0.05 Allsop and Ackland16

*Odds ratio. #Confidence intervals. aPrevalence ratio.

Protective factors for musculoskeletal disorders by body site.

Body site Factor OR* 95% Cl# p value Author
Neck Regular physical exercise 0.35 0.22–0.56 Baskurt et al.7
Age (≥40 years) 0.55 0.37–0.83 Baskurt et al.7
Neck/shoulder Physical exercise per week ≥ 7 hours 0.55 0.35–0.85 Yue et al.6
Back pain Regular physical exercise 0.52 0.34–0.82 0.004 Beyen et al.13
Age (≥40 years) 0.66 0.44–0.99 Baskurt et al.7
Satisfaction with working environment and culture 0.55 0.36–0.86 0.009 Beyen et al.13
Upper extremities Regular physical exercise 0.51 0.33–0.76 Baskurt et al.7
Having other paid activity 0.81 0.66–0.99a Cardoso et al.3
Lower extremities Having other paid activity 0.86 0.76–0.99a Cardoso et al.3

*Odds ratio. #Confidence intervals. aPrevalence ratio.

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